Saturday, January 25, 2014

[Note: In this post, I use the terms ‘junk food’ and ‘less
healthy’ foods in quotes and interchangeably to mean foods and beverages which
are high in calories but low in nutrients.I am using the same terms that a consensus of nutrition researchers use; I am not making a value judgement.]

Being over fat (i.e., having excess adipose tissue)
increases inflammation and disease.Increased
body size stresses joints and increases musculoskeletal instability.Reducing the personal, societal, medical and
economic burden resulting from these conditions is not going to be easy.Some suggest that strategies from tobacco
control may help.I agree that we can
use or modify tobacco control strategies to address ‘obesity’, but at the same
time, we should recognize that some of those strategies, e.g., shaming people and
offering one on one behavior change counseling are not likely to be effective.

Instead, I suggest we apply tobacco related strategies to
the structural causes of over fatness.The strategies that had the greatest influence on decreasing the
prevalence (percent of the population) of smoking targeted the physical and
social environment, not individual smokers.Successful strategies included price increases thru state and federal taxes,
age limits, clean air laws, advertising limits and display bans.(Warning labels are another strategy meant to
deter tobacco use, but they are focused on the individual and do not have much
success with current smokers.)

We can apply several of the above tobacco strategies to
‘obesity.’The first is price.A sin tax or ‘junk food’ tax is unpopular,
but it is effective in changing food/beverage purchasing behavior according to
some small studies.In order to implement
such a tax, we have to rely on current nutritional evidence about food
ingredients and then determine the best way to increase prices of items that
contain these ‘ingredients of concern’.For example,we know that adding
sugar and solid fats to foods and beverages makes them calorie dense and
calorie dense foods and drinks appear to be the main drivers of excess calorie
ingestion and over fatness in the US and similar countries.It is possible that taxing the ingredients
themselves, as some countries have done, will lead food manufacturers to reduce
their liberal use of sugar and solid fat. Another option is to tax the product
itself, such as sugar-sweetened beverages. This strategy could lead people to
purchase less of the taxed foods and beverages.A result of taxation could be that companies start providing less
calorically dense versions of their products (and not simply by reducing the
portion size!) or people start buying different products. These are not
mutually exclusive.

Another strategy we can apply is a modification of ‘clean
air laws.’ The overwhelming presence or availability of calorie rich, ‘junk
food’ also drives ‘junk food’ consumption. Tasty, cheap, calorie dense foods and
beverages are everywhere and even when people have the same access to fresh,
nutritious low calorie foods they tend to choose the ‘less healthy’ ones.My colleagues talk of food deserts – where
fresh produce is scarce -but I focus on food swamps.The main reason I believe food swamps, more
than food deserts, influence food choices relates to my work in tobacco
cessation and alcohol treatment programs.Consider being in a meeting or rehab and counseled to not smoke or drink
and then you leave the meeting and everywhere you go there are displays of
alcohol and cigarettes and people smoking and drinking. [Hence the advice to
alcoholics in recovery and recently quit smokers to change their playgrounds]. I
have had smokers tell me that they want their work places – and restaurants and
bars -to be smoke free (clean air laws), because it makes it easier for them to
work through their cravings.Their
personal stories are evidence that whatever makes smoking harder (or less
convenient, or less acceptable) makes quitting easier and smokers DO want to
quit. They just aren’t too keen on failing over and over again.The same desire and fear exists for people
who understand that certain foods are less healthy for them. People who struggle with calorie moderation
(i.e., all of us) have even more challenges. Because calorically dense foods are everywhere
– neighborhoods, stores, restaurants, worksites, schools – there is no other
playground for people to visit.The
playground (i.e., food swamp) is what must be changed.

The parallel to clean air laws for ‘obesity’ prevention are the
steps we take to break up food swamps – for example:zoning limits on the density of fast food
restaurants and convenience stores, work site policies (e.g., ‘junk food’ free
meetings), and candy free grocery checkout aisles.

The low cost and constant presence of ‘junk food’ is not the
only challenge to a maintaining an appropriate calorie level. We need to adopt
tobacco strategies related to advertisement and age as well.Food companies promote ‘less healthy’ food
and beverages on billboards, in TV shows and TV commercials, through other
media and in store displays.The ads
are entertaining, constant and often associated with celebrities.The food industry shapes the environment, it
shapes our tastes and it shapes our preferences. It makes sense for us to push
back against THEIR influence on our behavior and our health.

At this time, the only parallel to tobacco control for
advertising is predicated on age.Food
companies have voluntarily agreed to limit ‘junk food’ commercials during the
airing of children’s television.Another
age related parallel could be the restriction of vending machine use or vending
machine content in schools.The candy
free grocery aisles are also focused more on children than adults.

Lastly, nutrition information disclosures at restaurants and
vending sites may be a parallel to warning labels on tobacco products IF those
disclosures come with some type of interpretive label.For example, an entrée with 900 calories and
15 grams of sugar should be labeled as HIGH in those two ingredients. This is a more acceptable but weaker strategy.

It is important to remember that
progress in reducing the burden of disease from tobacco is taking many years,
but it began when people started to smoke less.We should start seeing a decline in lung cancer and other smoking
related conditions now as the prevalence of smoking has gone from 42% (1965) to
18 % (2013).The strategies that led to
a decrease in smoking were rolled out over time and met with great resistance,
especially from the tobacco companies.In fact, it took a near 50 state attorneys’ general lawsuit for tobacco
companies to admit that their product was harmful.

We have a long way to go in
reducing the personal, societal, medical and economic burden resulting from
over fatness, but cajoling people to eat less and exercise more in an
environment that makes it ridiculously easy to do neither is fruitless.

It’s the environment, stupid and
it is time we stopped letting the food industry control it.

Sunday, January 19, 2014

You have probably read news stories suggesting that calorie information on restaurant menus and menu boards does not work. It does appear that state or city nutrition menu labeling laws have not had a big impact on the average amount of calories customers purchase. However, I have noted several research studies that are exceptions to these findings and I continue to believe that providing nutrition information at the point of decision making is a good idea. The labeling can help reduce the over consumption of calories that occurs when people eat out. I also believe, based on the research of others (see e.g., Ellison), that using a traffic light presentation (i.e., green, amber or red based on calorie amount) will enhance the effectiveness of menu labeling.

For the most recent scientific review of menu labeling please click here.

Today I want to mention progress on another hoped for outcome related to menu labeling - changing the amount of calories in meals restaurants offer. The FDA still hasn't issued the final rule on how restaurants are to present the information, but in expectation, it would seem, restaurants are promoting special menus that offer lower than 'usual' calorie amounts. (Recall the studies I have cited in past posts which showed the average chain restaurant meal having over 900 calories.)

In my anecdotal review (i.e., I have not systematically studied restaurant menus before and after the legislation was passed, or as the final rule approaches, or controlled for the fact that it is the first of the year), I found at least 9 major chain restaurants (e.g., Apple Bees, Outback, Macaroni Grill, Subway, McAlisters, Long John Silvers, IHOP, TGIF) who are promoting entrees with 500 to 600 calories or less. Subway is advertising breakfast options at 200 or less.

One of the distal (or immediate) outcomes of a menu labeling law is that it heightens peoples awareness of calories and makes calories seem more important. I believe that menu labeling IS effective for these outcomes. The restaurant industry is aware of this and that is why menu labeling laws also work to change what is available - in other words, law can change the environment. Law can have a greater impact on population health than interventions aimed at individuals. I am confident that once the labeling rule is published and restaurants nationwide fulfill their obligations to post calorie information, we will begin to see a change in the amount of calories purchased and in the future, perhaps, a reduction in the prevalence of diseases associated with being over fat.

Tuesday, January 14, 2014

Two unusual diets that led to weight loss and the
improvement of metabolic profiles have been in the news lately.In an earlier draft of this paragraph, I was
harsh in calling out both dieters – a science teacher and a nutrition
professor. I felt and still feel that they should be mindful of their positions
of influence and temper their enthusiasm for diets that are probably unhealthy
and suspiciously fad-like.In addition,
both men offer simplistic explanations for obesity and unrealistic advice for groups
they appear to be judging.

In the first example, a high school science teacher, John
Cisna, eats meals from McDonald’s for 90 days, loses weight, and improves his
metabolic profile (i.e., his blood fat and cholesterol levels). Mr. Cisna
refers to his self-imposed diet as an experiment and determines that the
choices people make, not the food sold at McDonalds, makes them fat.

Mr. Cisna is correct; our choices have everything to do with
our outcomes.He is incorrect in
assuming that everyone has the same choices available to them. In his pseudo
experiment (more on that in a moment), he had his students choose his daily
meals within certain parameters.The
parameters were that he consume 2000 calories a day and stay within the
recommended daily allowances of certain macronutrients (e.g., total and
saturated fat).The local McDonald’s
franchise covered the cost of the meals. In news stories about his 90 day diet, Mr.
Cisna points out that he had to be smart about what he was doing.If he ate a high fat breakfast, he would have
to choose a lower fat lunch or dinner in order to stay within his parameters. This
is exactly what the Dietary Guidelines for Americans tell us to do, and what so
many of us have trouble doing.Mr. Cisna
is an educated man with above average numeracy who had 3 people watching the
numbers with him. He was also able to make choices among all price ranges. In
some of Mr. Cisna’s interviews, he suggests that people who blame McDonalds for
their obesity lack self-control. I do not expect, nor should he, that the
average McDonald’s customer has his same math skills or assistants to help them
track their calories. And tracking calories and other macronutrient amounts IS
important. We already know from scientific study that fast food and sit down
restaurants generally serve foods that contain at least a half a day’s worth of
calories, fat, sugar and salt.People
who obtain most or all of their meals from fast food and sit down restaurants,
especially in the absence of nutrition labeling – and math skill - are at great
risk for consuming a diet that is harmful to their health.

In addition to controlling his calories, which he did not
do before the McDonald’s diet, he also began exercising for 45 minutes a
day.

Mr. Cisna’s diet plan was not an experiment and we cannot
make causal inferences from his personal results. An experiment by definition
requires multiple subjects randomized into treatment conditions, including one
in which nothing changes.In most
situations, if a person reduces their caloric intake and increases their
exercise they will begin to lose weight and this initial weight loss will
improve their metabolic profile, especially if they are following the
recommended nutritional guidelines.Because
Mr. Cisna’s 90-day diet was not in any way an experiment, I am left with a few
questions: What would happen if he did this for 90 more days?What if he ate at McDonald’s but did not have
the nutrition information available to help him stay within his
parameters?What if he had very little
money with which to purchase the food?What
would happen if a woman followed his exact plan?Or a younger person or an older person or a
person of a different ethnicity?What
if he did this for 6 mos. or a year or for his whole life, as some seem
pressured to do?

In the second example, a nutrition professor, Dr. Mark Haub, eats
Twinkies, etc., for 10 weeks, loses weight and improves his metabolic profile.
He refers to his diet as a class project stemming from his teachings in
nutrition.I am just aghast by this, but
as I researched him a little further, I saw that his doctorate is not in
nutrition; it is in exercise science/physiology.Dr. Haub has also been vocal about his
results and suggests that the convenience store diet – something people living
in food deserts might be forced into – are not necessarily bad and will not lead
to obesity– as long as one makes the right choices.

I feel that Dr. Haub’s extrapolations are out of place and
far too simplistic.It feels like an
example of an over educated, privileged person suggesting he knows what an
‘other’ less privileged person is experiencing.

He claims that his convenience store diet, which for him
meant that 2/3 of his calories came from snack foods, caused his weight loss
and improved his metabolic profile.Like
Mr. Cisna, Haub did not conduct an experiment and headlines misrepresent what
he actually did.

Professor Haub consumed a lot of sugary, processed snacks
similar to and including Twinkies, but he also ate some vegetables, took a
multivitamin and drank protein shakes. In
addition, and this is huge, he reduced the amount of calories that he consumed
- from 2600 to 1800.

I have the same concerns and questions about this diet as
I did the McDonald’s one.I suspect that the
reason for Dr. Haub’s weight loss is that he reduced his intake by 800 calories.(He has told reporters that he monitored this
closely by writing down everything he ate.) I further suspect - and evidence supports
- that over time, a diet high in processed, sugary cakes will lead to metabolic
irregularities and poor health. Lastly,
and most importantly, he made a statement to one reporter that he wanted to be
able to say that the diet was unhealthy, but the “data doesn’t support
that.”The data do not support anything…
it was not an experiment or a quasi-experiment.It was not research – there are no ‘data’.

Both Dr. Haub and Mr. Cisna put themselves on a diet to lose
weight.During the time that they were
on the diets, counting calories and exercising, they lost about 30 pounds
each.This weight loss may have
triggered improvement in their metabolic profiles as well – this is an
assumption because we do not have a counter-factual or comparison group.It makes sense that the weight loss did cause
the improvement. It does not make sense to suggest that a long-term diet of
processed foods high in sugar or fried foods high in fat and sodium is health
promoting.Science already tells us that
there are adverse consequences to this kind of diet pattern. Both men’s claims as presented in the media
are misleading. Cisna did not eat McDonalds without careful attention to
calories and the macro-nutrient content of his meals, his choices were not
limited by cost and he significantly increased his exercise. Dr. Haub’s diet
included vegetables, protein shakes and vitamins; this is not similar to a diet
consumed by someone who has limited income and has to eat most of their meals
from a convenience store.

In my opinion, the headlines and the diets they report are
pure sensationalism.Please, choose your
calories from foods with health promoting properties, like those recommended by
the Nutrition
Source at Harvard.

Friday, January 10, 2014

Sorry, there is no such thing. My headline should be,
“Weight Loss Not Easy,” but then fewer people would read the post - and people need to read this post.Right now, masses of people are searching for
that one pill, powder, or cream that will melt away excess fat with no
behavioral change required.Said pill,
powder, cream DOES NOT EXIST.It does
not! Think about this carefully.There
are more overweight/obese adults in the United States and similar countries
than there are normal weight adults. Because excess fat is associated with
disease and being overweight can affect ones physical and psychological health,
a simple remedy would be groundbreaking.If this remedy currently existed, 70% of the US would not be overweight.

Products promising weight loss – fast, substantial,
permanent, and painless – are simply fraudulent.Unfortunately, the makers of these products
do not have to submit them to clinical trials where efficacy is established or
to post market trials where effectiveness is established – i.e., the FDA does
not regulate the products.However, the
companies that sell supplements/weight loss products must tell the truth about them
in advertisements.

Truth in advertising is a law and the Federal Trade
Commission (FTC) is responsible for its enforcement.The FTC is understaffed and it takes years
for them to get a falsely advertised product off the market.The FTC went after 4 companies this week –
read here,
and has started the year with increased efforts to protect consumers, updating
their guidance to both businesses and consumers for the first time since 2003.

I like the guidance the FTC provides to businesses, because
in their communication to them, the FTC enlists the support of businesses and
suggests that by screening the ads that they publish, businesses are protecting
themselves from being associated with a ‘bad’ company – an unscrupulous
company.This is a good strategy because
if media polices the ads, the FTC caseload could be reduced.The FTC could go after and prosecute
violators quicker.I will benefit, too. There will be fewer sensational, commercials
that raise my blood pressure.

The FTC encourages media to stop and think about an ad
before publishing or airing it. They offer 7 ‘gut checks’, but I can be more
concise.If an advertisement sounds too
good to be true, it is too good to be true. You cannot lose weight if you do
not change something about your eating and activity: the number of calories you
consume, the type of calories you consume, the amount of exercise you do, the type of exercise you do. It is best to address all of these, but research
suggests that diet alone will work to some extent.

The scientific study of fat gain and loss is dynamic.It feels like we learn something new every
day, and indeed some of the things we believed to be true are not.(I didn’t ‘know’ this before grad school, but
in science things are never proven, only disproved).Nutrition scientists once thought that all
fat was bad in excess, but that no longer appears to be true.They, and we – the public, also believed that
a calorie is a calorie, but that truism is under current scrutiny as well.I tell you this because I know many of you
have become frustrated with and distrustful of science.That is no reason to turn to supplement
makers, I assure you; the makers of weight loss supplements deserve much less
of your trust.The fact that we are
learning more about fat gain and loss through science is a good thing.One of the most important new findings is
that being over fat – as a population or as individuals – is caused by multiple
factors.Researchers have not identified
all the factors, and the ones they have identified are not completely
understood.But we know some things in
the aggregate.For example, calories (amount and type) matter most and genetics matter
least (by matter, I mean the amount of impact these factors have on body
fatness).Somewhere in between these two
extremes is the amount and type of physical activity one engages in and metabolism.An important note about metabolism is
this:an individual’s metabolism is
affected by what and how much he or she has eaten over his or her lifetime and the
amount of body fat he or she has carried.In other words, a metabolism can become dysfunctional and this
individual dysfunction makes it hard for anyone to prescribe generic weight
loss advice - not everyone who cuts their calories and increases exercise will
have the same results.This is the
painful truth.In addition, I’d like to
disavow you of the notion of a set point weight.Instead, consider this: if a person does a
certain thing and loses 10 pounds but then stops doing that certain thing,
their weight will return to its previous level.That is not destiny – the weight returned to its previous level for a specific
reason – a person’s actions.

In summary and in closing, no diet supplement leads to easy
weight loss.In the absence of disease,
body fat does not melt away. Please
consider this before you spend your money and invest your hopes in a weight
loss supplement. The FTC is cracking down on companies who market products as
if the products were weight loss miracles, and is asking businesses to give ads a ‘gut
check’ before they agree to publish them.Losing excess body fat is important and safe ways to do so exist.One way to maintain a healthy weight is to follow the
guidelines suggested by the Harvard
Nutrition Source and to commit to daily or near daily exercise that increases
your heart rate for 30 or more minutes.

Tuesday, January 7, 2014

In December the United States Preventative Task Force completed its review of the available science on whether using a low dose CT scan could reduce the number of lung cancer deaths. Lung cancer is the most lethal cancer, likely due to its late detection. Treatment in late stage lung cancer is seldom successful, and is invasive (i.e., surgery, radiation, chemotherapy). The task force members reviewed 6 effectiveness studies and 20 studies that explored adverse effects from low dose CT - including exposure to radiation, the rate of false positives and the associated stress and unnecessary procedures that follow false positives. You can read the summary and full report from the task force here. It appears that only one of the studies that found a protective effect from low dose CT was of high quality. That study showed reduced lung cancer death as well as reduced death from any cause (all cause mortality) in the smokers who received the CT. The evidence from this study and several moderate quality studies was convincing enough to some to recommend the screening change. I am addressing the issue in my blog for two reasons, 1) I have worked in the smoking cessation field and 2) I often post about medical radiation and my grave concern over excessive use of imaging. Almost four years ago, I wrote this post which was an over view of chapter 4 in the President's Cancer Panel report on Reducing Environmental Cancer Risk. Chapter 4 is Exposure to Hazards from Medical Sources. From that chapter we learned that CT scans are over used, that they expose the patient to high levels of radiation (higher levels than are necessary for the scans to be effective) and that the radiation dose from a CT scan can increase a person's risk for cancer. The new recommendations are for physicians to offer the low dose CT (LDCT) to persons who are between the ages of 55 and 74 who have smoked 1 pack of cigarettes per day for 30 years or 2 packs per day for 15 years, or any other combination that would equal 30 pack years. If a person has this smoking history, but has quit smoking, they should still have the screens if they have been smoke free for less than 15 years. [Notice the significant screening criteria - SMOKERS only. To me this is as strong a declaration on the lethal consequences of smoking as one will ever hear.] According to the task force, 20% more lung cancer deaths could be prevented if these heavy smokers were screened with LDCT instead of a chest x-ray. I do not know what this means in actual numbers, i.e., 20% of how many - how many do X rays find? What I did spend time looking for was the amount of radiation a low dose CT provided. Recall from chapter 4, not all imaging machines deliver the same amount per test .. so a rough estimate is the best we can do. The estimate is that low dose CT delivers the radiation equivalent of about 15 xrays. Fifteen! Radiation in this case is measured as millisieverts, or mSv. A regular chest CT has 5 to 20 mSv and the low dose CT has 1 to 4 mSv. Better - still a heck of a lot and more than I would routinely expose myself to. (To be fair, some estimates of the radiation in regular chest CT suggest the equivalence of 350 Xrays... yes that is three hundred - so to answer my question; indeed, the low dose CT is a lower dose of radiation) In the summary from the report, it is clearly stated that most lung cancer is caused by smoking and that the most important thing we can do to reduce death and disease from lung cancer is to reduce smoking.I am really concerned that smokers will keep smoking because they believe that this screening will find a tumor in time to remove it. That is a HUGE risk. Click here to learn more about quitting.. I did it, so can you.

Wednesday, January 1, 2014

In a word, NO. That was rather simple and probably not fair and certainly out of my professional realm. It's more appropriate for me to recommend that you think twice before having a 3D mammogram. At this time, there is little evidence that the 3D scan is more effective at detecting cancerous lumps and reducing false positives on its own, though early results suggest it might be helpful at doing that when used at the same time as the 2D digital mammogram. (Please see the linked article for a very interesting history on how the 2D mammogram replaced the Screen Film Mammography before research indicated that it should. spoiler: it never really did)At this time, it makes more sense for women to continue with the usual, insurance covered (actually free because there is no copay for this covered preventative service) 2D digital mammogram. At least one large clinical trial is currently underway to determine if the 3D scan, actually called Digital Breast Tomosynthesis or DBT is better than the 2D alone and whether or not the improvement is worth the extra radiation. The DBT is similar to a CT scan, which I have discussed in past posts.

The reason I wanted to look into the 3D evidence is because for the last two years when I went in for my screening, I was asked by the imaging center staff - not my doctor - if I wanted the 3D scan. It is not covered by insurance - its not free anyways. The first year I asked why? Why would I want this type of imaging? I am pretty certain that the radiology tech told me that the 3D exam gives a clearer image and may reduce false positives (which appears to be true). I then asked, "is there more radiation?" The answer was yes so I declined this 'better' test. This year, a few weeks ago, the image center receptionist asked me if I wanted the 3D scan and when I said NO without hesitation, I was told to read and sign a WAIVER form. I was documenting that I was offered the 3D scan and declined it. That was odd, so I asked, "Do you make people who agree to the exam sign a form too?" She said yes, and I should have asked to see it, because the feeling I had at the time, as the patient, was that they were trying to scare me into getting an exam - without clinical indication and at extra cost to me. Why would they do that? I expect because the imaging center makes a profit from it.

I would like to see the results of a randomized clinical trial that compares the 2 types of mammograms. Based on my strong concern over radiation, I expect that even if the 3D comes out ahead, I will skip it... remember radiation is itself a cause of cancer. That is my PERSONAL informed decision; you must make your own informed decision.

Click here to see a document listing what is known and unknown about this type of imaging to date. It includes information on the large clinical trial that is still under way - The Oslo Screening Trial.

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